Risk-assessment tool makes sure clots are prevented whenever possible

Where: University of California at San Diego (UCSD) Medical Center, a 325-bed hospital.

The issue: Reducing the incidence of venous thromboembolism (VTE) by increasing the use of prophylaxis.

Background

Physicians at UCSD suspected that although VTE prophylaxis is effective, it was being
widely underused at their hospital. The VTE Prevention Team, led by Gregory A. Maynard,
ACP Member, confirmed their assertion that prophylaxis rates were low by doing a random
audit of inpatient charts. In the 2005 assessment, they found that only about 50%
of patients were being protected against clots. To get that number up, the team of
pulmonary specialists, hospitalists and others developed an institution-wide prophylaxis
protocol. The project was funded by the Agency for Healthcare Research and Quality.

How it works

First, the team members built a consensus about the standards for assessing VTE risk
and choosing appropriate prophylaxis. Then they created a standardized tool that separates
patients into three tiers—low, medium or high VTE risk.

A healthy ambulatory patient would be low risk, whereas a hip fracture or spinal cord
injury patient would be high risk, for example. The tool (see Table), incorporated into UCSD's electronic medical record, then prompts physicians at
each admission or transfer to assess the patient's VTE risk.

After patients are categorized, the tool suggests appropriate prophylaxis options,
such as heparin or compression stockings. “Each level of VTE risk was linked
to a menu of acceptable prophylaxis options,” said Dr. Maynard.

The team found that more than 80% of their patients fall into the medium risk category,
for which pharmacologic prophylaxis was recommended. Overall, about 95% of the assessed
patients are candidates for pharmacologic prophylaxis when it's not contraindicated.

The challenges

“There is no gold standard for adequate prophylaxis for any given patient,
so achieving consensus on a VTE prevention protocol and a risk assessment model that
the medical staff would buy into was a hurdle,” said Dr. Maynard.

To overcome this, the VTE Prevention Team held a series of meetings with the institution's
divisional leaders. “Sometimes gaining support took showing them an anecdote
of a patient who failed their preferred mode of prophylaxis,” he said. The
team also began using digital imaging to screen for VTE and pulmonary embolisms (PE)
daily. “This opened everyone's eyes to the actual number of VTE and PE that
were occurring in the medical center. It was a much larger number than most casual
observers would guess because individual physicians don't see their own patients [have]
many VTEs or PEs during the year,” said Dr. Maynard.

Another barrier was the lack of a prospectively validated risk-assessment model in
the literature. “To overcome this, we originated one,” said Dr. Maynard.
The team looked at the existing research and came up with a model they thought would
work. “The ultimate validation was putting that model into place in the form
of an order set and reducing VTE and PE,” Dr. Maynard said.

Results

When UCSD measured prophylaxis rates in 2005, they ranged between 50% and 70%. By
the end of 2006, the use of clot prevention hovered at 80%.

“It wasn't until 2007 when we were consistently above 90% that we had a real
impact on our patient populations and their risk for VTE or PE. And now in 2008 we've
been at 97% for the entire year,” said Dr. Maynard. Continuing analysis of
the program found that the moderate-risk group saw the largest reduction in hospital-acquired
clots, and overall rates of clot events have dropped by about 35%.

The program was so successful that the VTE prevention protocol has become the foundation
of a VTE Prevention Collaborative, which was organized by the Society of Hospital
Medicine (SHM) and so far includes 30 medical centers. As part of the collaborative,
Maynard connects via phone and email with hospitalists across the country who are
dedicated to increasing VTE prophylaxis at their facilities.

Lessons learned

The simpler the risk assessment model the more likely it is to be integrated seamlessly
into the workflow. “An ideal VTE risk assessment model does not require the
user to add up points [to ascertain the patient's risk level],” said Ian H.
Jenkins, ACP Member, a hospitalist and member of the VTE Prevention Team. “Also,
the model has to be convenient, but still maintain an adequate level of accuracy and
detail.”

Measurement drives improvement. “If it's done correctly with sampling and/or
automation, and if you use digital imaging, like we did, you can get good data without
a burdensome amount of work,” said Dr. Maynard.

How patients benefit

Of course, UCSD patients benefit from the reduction in PE and VTE, which is the leading
cause of preventable death in hospitalized patients. Patients at other hospitals are
now benefiting from the spread of the protocol.

Next steps

Dr. Maynard said there's still work to be done as long as hospital- acquired VTE has
not been eradicated. “There are still a lot of cases where there's a relative
contraindication to pharmacologic prophylaxis, so clinicians justify not putting these
patients on prophylaxis because of that. But the risk of clots is probably higher
than the risk of bleeding from pharmacologic prophylaxis, so we plan to focus more
on those patients,” he said.

The team also continues to collect data on VTEs and use that knowledge to further
refine the system. “When patients develop a clot, we investigate why,”
said Dr. Jenkins.

Words of wisdom

“Don't reinvent the wheel. Use the VTE Prevention Collaborative tools on the
SHM Web site. We put a lot of information into the toolkit that people can use to
achieve the same results much more quickly than we did,” said Dr. Maynard.

“If you involve and solicit the advice of everyone who may have their workflow
altered, you'll have allies rather than people who you are trying to make compliant,”
said Dr. Jenkins.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.